Acetylcholinesterase inhibitors are the mainstay of treatment of Alzheimer’s disease. However, in the majority of studies the proportion of patients demonstrating a significant clinical improvement under treatment does not exceed 40%. A routine method of identifying responders in clinical practice is the assessment of change in their cognitive functions during treatment. This review presents the available data on predictors of response to acetylcholinesterase inhibitor therapy in Alzheimer’s disease – factors allowing the prognosis of a patient’s reaction to treatment (in terms of target symptoms and tolerance) at its very beginning or even before therapy has been initiated. A variety of predictors will be discussed: genetic factors (apolipoprotein E, butyrylcholinesterase, choline acetyltransferase), demographic factors (age, gender), clinical factors (severity and rate of progression of dementia, comorbid neuropsychiatric symptoms, vascular risk factors, response to the test dose of the drug, results of neuropsychological testing, orthostatic hypotension), and work-up results (SPECT, MRI, EEG). The ability to predict patient’s response to treatment would allow a precise choice of szczególdrug for a given patient, taking into account its clinical efficacy in different subpopulations and potency for the generation of side effects, could also help cut down the global costs of prescribing those medications, and stimulate research on the biological mechanisms of Alzheimer’s disease. Altogether, the current level of knowledge on predictors of response to acetylcholinesterase inhibitors, with good tolerance and benign side-effect profile of this class of drugs, and lack of alternative, more effective methods of treatment of Alzheimer’s disease cannot entitle the physician to give up on the introduction of treatment in any single patient.
Dementia with Lewy bodies (DLB) is considered to be the second most frequent primary degenerative dementing illness after Alzheimer’s disease. Psychotic symptoms are typical features in DLB patients, and visual hallucinations are the most frequent neuropsychiatric symptoms and have been considered as one of the core features in the clinical diagnostic criteria of DLB. According to literature, spectrum of delusional ideation may be observed in DLB cases. There is a serious problem of misdiagnosis in cases with delusional ideation in DLB cases. The diagnosis of senile psychosis is frequently made duo to visual hallucinations and delusions. Moreover, diagnosis of delusional parasitosis (form of monodelusional disorder, known as Ekbom’s syndrome) must be taken into account during differential diagnosis. Subjects with delusions of being infested with parasites frequently consult many specialists (dermatologists, internists or allergists) and usually reject psychiatric diagnosis and treatment. Unfortunately, there is a limited evidence of the efficacy of specific pharmacologic interventions, but severe sensitivity to typical and atypical antipsychotics in approximately 50% can occur, and improvements in visual hallucinations with cholinesterase inhibitors could be expected. Herein, we report two cases of DLB suffering due to delusions of being infested by parasites (delusional parasitosis). The paper demonstrates the clinical picture and utility of cholinesterase inhibitors and low doses of second generation antipsychotics in the treatment of psychosis in the DLB cases.
PL
Otępienie z ciałami Lewy’ego (DLB) to druga (po chorobie Alzheimera) przyczyna otępień pierwotnie zwyrodnieniowych. Objawy psychotyczne należą do typowych symptomów DLB, a omamy wzrokowe, najczęstsze w tej grupie objawów, uznano za kluczowy objaw i umieszczono w klinicznych kryteriach diagnostycznych. Jak wynika z piśmiennictwa, u chorych z DLB można zaobserwować całe spektrum treści urojeniowych. Podkreśla się również ryzyko postawienia błędnej diagnozy z powodu treści urojeniowych obecnych u chorych z DLB. Współwystępowanie omamów wzrokowych i urojeń najczęściej skutkuje ustaleniem rozpoznania psychozy starczej. Co więcej, urojeniowa parazytoza (psychoza monosymptomatyczna zwana zespołem Ekboma) powinna być brana pod uwagę w trakcie diagnostyki różnicowej. Ze względu na specyfikę objawów chorzy z urojeniami zakażenia parazytami często zasięgają opinii różnych specjalistów (dermatologów, internistów, alergologów), a odrzucają rozpoznanie psychiatryczne i odmawiają leczenia psychotropowego. Niestety, istnieją jedynie ograniczone dane na temat skuteczności specyficznych interwencji farmakologicznych, a po zastosowaniu neuroleptyku u około 50% chorych z DLB odnotowuje się poważne reakcje nadwrażliwości. Poprawy w zakresie omamów wzrokowych można się spodziewać po włączeniu do leczenia inhibitorów cholinesterazy. W pracy przedstawiono dwa przypadki pacjentek z DLB doświadczających urojeń choroby pasożytniczej (urojeniowa parazytoza). Zaprezentowano obraz kliniczny psychozy oraz przydatność inhibitorów cholinesterazy i małych dawek leków przeciwpsychotycznych w leczeniu psychozy u chorych z DLB.
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